Process Medicare Safety Net claims 011-43080040

Where an account has been paid in full, the system automatically calculates the Medicare benefit payable.

If an Extended Medicare Safety Net (EMSN) threshold has been reached, the system pays the Medicare benefit and the lower of either:

• 80% of the out-of-pocket (OOP) expenses
• the EMSN benefit cap

If the Original Medicare Safety Net (OMSN) threshold is reached, the Medicare benefit for eligible services increases from 85% to 100% of the schedule fee for the rest of the calendar year.

Note: general practitioner (GP) services are already paid at 100% of the schedule fee, so no additional benefit applies under the OMSN threshold.

The Resources page contains an example of how the system calculates the benefit for fully paid accounts when a Medicare Safety Net threshold has been reached.

Legislation provides that when an individual has reached an Extended Medicare Safety Net (EMSN) threshold, they only need to pay up to 20% of the out-of-pocket (OOP) expenses. Therefore, partially paid accounts can be accepted where at least 20% of the OOP has been paid.

In some cases, the claimant pays 20% of the OOP. The health professional is reimbursed the Medicare benefit plus the lower of either:

• 80% of the OOP
• EMSN benefit cap

The additional benefit is paid to the health professional through a pay doctor via claimant (PDVC) cheque.

If the item is subject to an EMSN benefit cap, the claimant's 20% contribution may not be enough to pay the account in full. In these circumstances, the account is treated as an unpaid account.

Partially paid accounts can be lodged digitally or manually.

These claims must be verified immediately after processing.

For more information about EMSN capping, see Extended Medicare Safety Net (EMSN).

Through the online channel by a health professional

When a Medicare claim with a partial payment is lodged through the online channel, service officer intervention is required. The medical practice will advise of any partial payments already made by the claimant. They will have a return message of 1-SNET PND.

Note: online partial payments cannot be modified

Through digital self-service or manual patient claim

Partial payment claims lodged via digital self-service or a manual patient claim display the return message 1-SNET PEND.

1-SNET PEND displays when the system cannot automatically verify the OOP and manual intervention is required. The system cannot determine whether the payment has been allocated, whether the account has been partially paid, or how the OOP should be distributed across the claimed items.

The Medicare system automatically processes partially paid accounts where the claimant has paid exactly 20% of the OOP cost.

When processing a claim where exactly 20% of the OOP has been paid, the system prompts the service officers to enter the amount paid by the claimant. The system then automatically calculates the benefit payable.

The Resources page contains an example of when exactly 20% of the OOP has been paid.

If the claimant has paid less than 20% of the OOP cost, the Medicare system asks for the partial payment to be keyed because it cannot calculate the benefit until all figures have been entered.

When the system identifies that the partial payment is less than 20% of the OOP, the message '8-PPMT<20%' displays.

These claims are processed as unpaid. The pay doctor via claimant (PDVC) cheque is issued for the Medicare benefit only. Verification is required before any additional benefit can be paid.

The statement on the PDVC cheque, 'Extra benefits may be paid with proof of payment to Medicare', advises the claimant that further benefits may be payable once proof of payment is provided.

Where the claimant is:

• Present or contacted via telephone:
  • Service officers should advise that this claim will be processed as unpaid, only paying the standard Medicare benefit. Alternatively, when the claimant pays the account, an additional benefit would be payable
• Not present, for example, claims lodged by post or digitally:
  • The claim is to be processed as unpaid

The Resources page contains an example of when less than 20% of the OOP has been paid and verification is required before any additional benefit can be paid.

Claimants may sometimes pay more than 20% of the OOP cost because the health professional does not know the exact 20% amount.

In these cases, the benefit payable from the claim must be split between the health professional and the claimant.

If the claimant has paid more than 20% OOP, but less than the health professionals charge, the claim is processed by recording the amount of the partial payment when prompted.

Only the difference between the Medicare benefit and the health professional’s charge is allocated to the EMSN. Any additional amount paid is a matter between the claimant and the health professional.

The Resources page contains an example of when more than 20% of the OOP has been paid.

If the claimant has paid more than 100% of the OOP, service officers are prompted to enter the partial payment amount and should process the claim as more than 20% of OOP paid.

This may occur where a claim includes multiple items and the partial payment has been allocated to only one item. It may also occur for a single item.

The Resources page contains an example of when more than 20% of the OOP has been paid.

Health professionals must provide the following details on an account:

• date
• amount charged
• total amount paid
• amount outstanding

This information helps service officers determine if an account is unpaid, fully paid or partially paid. The amount paid by the claimant and any outstanding balance must be shown on the account.

If this information is not included on the account, the claim is to be treated as unpaid and processed as a pay doctor via claimant (PDVC) cheque for the standard Medicare benefit only. Advise the claimant to pay the outstanding balance as per current procedure.

If the amount paid is less than 20% of the OOP cost, the account is treated as unpaid.

The Resources page contains an example of when less than 20% of the OOP has been paid.

When an unpaid account is claimed, the system generates a pay doctor via claimant (PDVC) cheque for the appropriate Medicare benefit.

When the threshold has been reached, the system prompts the service officer to key a partial payment amount. Key $0.00 if no partial payment has been made.

The statement 'Extra benefits may be paid with proof of payment to Medicare' is included on the statement of benefit to advise the claimant that additional benefits may be payable once the account has been paid and verified by Medicare.

To claim the additional EMSN, the claimant must provide proof of payment so the payment can be verified. When the payment is verified the system calculates and pays the lower of either:

• 80% of the OOP
• EMSN benefit cap

The Resources page contains an example of when an unpaid account is claimed.

It is possible for a dependant to be enrolled on more than one Medicare card. These dependants can also be registered with more than one Safety Net family.

When processing a claim service officers must ensure they allocate the Safety Net benefit to the family who incurred the cost of the service. The Process page contains processes for selecting the correct Safety Net family when processing claims and adjustments.

Note: dependants can be registered on a maximum of 2 Safety Net family registrations.

See Medicare Safety Nets

8-CONFIRM message displays when processing a claim. It applies to out of hospital claims where the account is fully paid or the gap has been paid.

If a claim for a fully paid or partially paid account returns an 8-CONFIRM message, the claim is only processed when it has been confirmed that the Safety Net threshold will not be exceeded.

See Resources page > Table 8